bariatric surgery in the transplant population

Bariatric Surgery in the Transplant Population

Guilherme M. Campos, MD, FACS, FASMBSAssociate Professor of Surgery

University of Wisconsin – Madisoncampos@surgery.wisc.edu

5th Annual Wisconsin Chapter Transplant Symposium

Transplant: Sharing and Caring

1. Overview of Bariatric Surgery1. Indications2. Type of procedures3. Peri-operative and long term-outcomes4. Beyond Caloric Restriction, why does it work

2. Bariatric Surgery & Organ Transplantation1. UCSF Data2. CRF (with or without dialysis / pre Kidney Tx)3. Post Kidney Tx4.Before, during and after Liver Tx

Bariatric Surgery Before and After Organ Transplantation

Surgery for Severe ObesityN

o. o

f Ba

ria

tric

Sx.

in th

e U

S

Recent trends in bariatric surgery case volume in the United States.Kohn GP, Galanko JA, Overby DW, Farrell TM.Surgery 2009 146: 375-80

1. Increasing prevalence and recognition Health Hazard

2. Poor outcomes with nonsurgical management

3. Good outcomes with Bariatric Surgery

4. Introduction of Laparoscopic Techniques

Surgery for Severe ObesitySteinbrook RN Eng J Med 2004 350: 1075-79

• Failure supervised weight loss program

• Well-informed and motivated patients

• Acceptable operative risks

• BMI > 40 or BMI 35-40 with high risk comorbidities

Surgery for Severe Obesity

PATIENT SELECTION

NIH Consensus Statement – March 25-27, 1991 Nutrition 1996; 12: 397-402

LaparoscopicGastric Bypass

LaparoscopicGastric Banding

60% 25%

LaparoscopicSleeve Gastrectomy

20%

1. Low perioperative and long-term complication rate.

2. Significant and Long Term Weight Loss

3. Improvement/Cure Obesity Associated Comorbidities

4. Improvement Quality of Life

5. Reduces Mortality

Bariatric Surgery Overview O U T C O M E S

• A prospective, multicenter, observational study of 30-day outcomes in consecutive patients

undergoing bariatric surgical procedures at 10 clinical sites in the US from 2005 - 2007.

• 4,340 patients who had a first-time bariatric procedure

1. Open RYGB - 899 patients (21%) - BMI 51

2. Laparoscopic RYGB - 2243 patients (51%) - BMI 47

3. Laparoscopic Band - 1198 patients (28%) - BMI 44

Significant Differences in between all groups/p<0.01/ for BMI and Co-existing Conditions

(Other procedures - 166 patients, not included in the analysis)

1. Low perioperative and long-term complication rate.

2. Significant and Long Term Weight Loss

3. Improvement/Cure Obesity Associated Comorbidities

4. Improvement Quality of Life

5. Reduces Mortality

Bariatric Surgery Overview O U T C O M E S

Effects of Bariatric Surgery on Mortality in Swedish Obese SubjectsSjöström et al. NEJM. 2007; 357 (8):741-52

1. Low perioperative and long-term complication rate.

2. Significant and Long Term Weight Loss

3. Improvement/Cure Obesity Associated Comorbidities

4. Improvement Quality of Life

5. Reduces Mortality

Bariatric Surgery Overview O U T C O M E S

% R

eso

lutio

n C

omor

bid

ityResolution of Obesity Associated Diseases after

Gastric Bypass

Buchwald H. et al. JAMA. 2004; 292(14):1724-37

48%

75%80%

12 Studies, 576 patients, RYGB, 2cd Biopsy ~ 17 mo

STEATOSIS INFLAMMATION FIBROSIS

Improvement 100% 80% 80%

No Change - 10% 10%

Worse/New Onset - 10% (Portal) 10%

OUTCOME HISTOLOGY 2cd BIOPSY

• Ralph, 45 y/o, 394 lbs• On Disability for Back Pain• High Blood Pressure (3 meds.)• Diabetes• Sleep Apnea• Venous Disease

1. Low perioperative and long-term complication rate.

2. Significant and Long Term Weight Loss

3. Improvement/Cure Obesity Associated Comorbidities

4. Improvement Quality of Life

5. Reduces Mortality

Bariatric Surgery Overview O U T C O M E S

Original Article Long-Term Mortality after Gastric Bypass Surgery

Ted D. Adams, Ph.D., M.P.H., et alUniversity of Utah School of Medicine

Salt Lake City, UT

N Engl J MedVolume 357(8):753-761

August 23, 2007

Original Article Effects of Bariatric Surgery on Mortality in Swedish

Obese SubjectsLars Sjöström, M.D., Ph.D., et al.

Swedish Obese Subjects (SOS) StudySahlgrenska University Hospital, Gothenburg, Sweden,

N Engl J MedVolume 357(8):741-752

August 23, 2007

Distribution of Deaths and Death Rates per 10,000 Person-Years, According to Study Group

Adams TD et al. N Engl J Med 2007;357:753-761

Cause of Death

Sjostrom L et al. N Engl J Med 2007;357:741-752

5% 6.3%

• Failure supervised weight loss program

• Well-informed and motivated patients

• Acceptable operative risks

• BMI > 40 or BMI 35-40 with high risk comorbidities

Surgery for Severe Obesity

PATIENT SELECTION

NIH Consensus Statement – March 25-27, 1991 Nutrition 1996; 12: 397-402

Beyond Caloric Restriction, why does it work?

Surgery for Severe Obesity

• Well-informed and motivated patients

NIH Consensus Statement – March 25-27, 1991 Nutrition 1996; 12: 397-402

• Change in Hunger-Satiety Mechanisms

• Change in Endocrine and Gluco-regulatory

Mechanisms

Cummings D.E. et al.

Ghrelin Secretion before & after Weight Loss

Cummings D.E. et al.

Ghrelin Secretion before & after GBP

BAGGIO LL & DRUCKER DJ Gastroenterology 2007;132:2131–2157

GLP-1 LEVELS AFTER A MEAL

Campos GM, et al.Journal of Gastrointestinal Surgery, Jan; 14 (1):15-23, 2010

Campos GM, et al.Journal of Gastrointestinal Surgery, Jan; 14 (1):15-23, 2010.

* P=0.01

GLP-1 LEVELS AFTER A MEAL

INSULIN LEVELS AFTER A MEAL

Campos GM, et al.Journal of Gastrointestinal Surgery, Jan; 14 (1):15-23, 2010.

* P=0.01

- Gastric Bypass Group

BAGGIO LL & DRUCKER DJ Gastroenterology 2007;132:2131–2157

1. UCSF Data2. CRF (with or without dialysis / pre Kidney Tx)3. Post Kidney Tx4. Before and after Heart Tx5. Before and after Lung Tx6. Before, during and after Liver Tx

Bariatric Surgery Before and After Organ Transplantation

4%

35%

4%

33%

18%

8%

0

5

10

15

20

25

30

35

40

< 18.5 18.5 - 24.9 25 - 29.9 30 - 34.9 35 - 39.9 > 40

BMI

Prevalence of Obesity in Patients Awaiting Kidney or Liver Transplant at UCSF - 2006

6%

18%

34%

8%

3%

32%

0

5

10

15

20

25

30

35

40

< 18.5 18.5 - 24.9 25 - 29.9 30 - 34.9 35 - 39.9 > 40

BMI

32% (n = 248) > 306% (n = 33) > 40

30% (n = 1,076) > 304% (n = 222) > 40

Liver (n = 986)Liver (n = 986)Kidney (n =4,144)Kidney (n =4,144)

Background%

of

patie

nts

% o

f pa

tient

s

Gore JL, et al. Am J of Transplantation 2006Pischon T, et al. Neph Dail Transplant 2001

• More post-op wound, pulmonary and cardiovascular complications

• Higher rate of primary graft non-function

• Longer length of hospitalization

• 30% higher cost of hospitalization

• Higher mortality

• More post-op wound, pulmonary and cardiovascular complications

• Higher rate of primary graft non-function

• Longer length of hospitalization

• 30% higher cost of hospitalization

• Higher mortality

KIDNEYKIDNEY LIVERLIVER

Nair S, et al. AJG 2001, Hepatol 2002Sawyer RG, et al. Clin Trans 1999

BackgroundMorbidity after Transplant - UNOS

• Higher rate of delayed graft function

• Higher rate of early graft loss

• Higher rate of acute rejection

• Higher rate of overall graft failure

• Longer length of hospitalization

• Higher mortality

• Higher rate of delayed graft function

• Higher rate of early graft loss

• Higher rate of acute rejection

• Higher rate of overall graft failure

• Longer length of hospitalization

• Higher mortality

Background

• Most transplant centers have implemented BMI limits beyond which patients are considered unsuitable for

transplantation.

• Bariatric surgery is the most effective treatment for morbid obesity, but is not offered routinely to this patient

population.

Laparoscopic Bariatric Surgery Improves Transplant Candidacy In Morbidly Obese

Patients

Takata M, Campos G, Ciovica R, Rogers S, Cello J, Ascher N, Posselt A

Bariatric Surgery Program

University of California San Francisco, USA

Objectives

• Evaluate the safety and efficacy of:– Laparoscopic gastric bypass - ESRD.– Laparoscopic sleeve cirrhosis and ESLD.

Patients and Methods

• Selected patients ineligible for a kidney, liver, or lung transplant because of their BMI.

• UCSF BMI limits for transplantation– Kidney: 40kg/m2

– Liver: 40kg/m2 (relative contraindication) and 50kg/m2 (absolute contraindication).

– Lung: 40kg/m2

ResultsOperative and Perioperative Outcomes

ESRD (n=19) Cirrhosis (n=14) ESLD (n=4)

Operation LGBP LSG LSG

Total O.R. time (min) 189 (148 - 222) 141 (120 - 176) 147 (90 & 213)

Mean EBL, ml 64 58 50

Complications 4 4 2

LOS, days 3.0 (3 - 3) 4.2 (2 - 8) 4.0 (3 & 5)

Follow-up, months 36 (6 - 36) 21 (3 - 21) 18 (9 - 18)

Bariatric Surgery Program

University of California San Francisco, USA

ResultsLGBP in Patients With ESRD

25

30

35

40

45

50

55

60

65

Preop 1 3 6 9 12

Time since Surgery (months)

BMI

25

30

35

40

45

50

55

60

65

Preop 1 3 6 9 12

Time since Surgery (months)

BMI

BMI Cutoff for Transplant

Transplant candidate at 12 months11/12

Bariatric Surgery Program

University of California San Francisco, USA

ResultsLSG in Patients With Cirrhosis / ESLiverD

25

30

35

40

45

50

55

60

Preop 1 3 6 9 12

Time since surgery (months)

BMI

25

30

35

40

45

50

55

60

Preop 1 3 6 9 12

Time since surgery (months)

BMI

BMI Cutoff for Transplant

Transplant candidate at 12 months6/9

Bariatric Surgery Program

University of California San Francisco, USA

1. CRF (with or without dialysis / pre Kidney Tx)2. Post Kidney Tx

32 patients CRF, RYGB, no Tx9 patients CRF, RYGB, Kidney Tx10 patients Post kidney, RYGB

1. Before Heart Tx

N=2Lap Sleeve

1. After Liver Tx

N=12 months after Liver TxBiliary reconstruction and Open SleeveBMI 37 to 30, 6 months post-op

1. After Liver Tx

N=21. BMI 65 to 48, 3 years post-op2. BMI 63 to 43, 18 mo post-op

1. CRF (with or without dialysis / pre Kidney Tx)2. Post Kidney Tx3. Before and after Heart Tx4. Before and after Lung Tx5. Before, during and after Liver Tx

Bariatric Surgery Before and After Organ Transplantation

LaparoscopicGastric Bypass

LaparoscopicGastric Banding

60% 25%

LaparoscopicSleeve Gastrectomy

20%

LaparoscopicGastric Bypass

LaparoscopicSleeve Gastrectomy

Patient Selection – Initial Procedure

1. for patients considered high-risk

2. for transplant candidates

3. for morbidly obese patients with Met Syndrome

4. for pts. BMI 30-35 and comorbidities

5. for pts. with Inflammatory Bowel Disease

6. adolescent morbidly obese patients

7. for elderly morbidly obese patients

LSG is a valid option

96%

96%

91%

95%

86%

77%

100%

Bariatric Surgery in the Transplant Population

Guilherme M. Campos, MD, FACS, FASMBSAssociate Professor of Surgery

University of Wisconsin – Madisoncampos@surgery.wisc.edu

5th Annual Wisconsin Chapter Transplant Symposium

Transplant: Sharing and Caring